The relationship of components within systems can be complex, often multidimensional. To understand and optimize a system we must understand what we see holistically. Look for performance gaps across and within the parts. Unintended consequences occur when a change to improve one component is done in isolation.

Systems either work well or are… unhealthy. Unhealthy systems have gaps and these gaps result in subpar performance. Systems thinking looks at what components are missing, what needs to be removed, where to improve. Then each piece is reconnected in a way that results in a healthy system. We "re-power a community" through systems thinking.

There are new tools for discerning gaps. Systems thinking has taken on broader dimensions because of:

In the Northern Neck of Virginia, the Center for Innovation and Development (CID) was created from systems thinking. We chose businesses from the Washington, D.C. area, Richmond, and Hampton Roads as ideal for collaboration with our rural community. For me, this is an exhilarating project. Our community will benefit from the intellectual and economic rewards associated with being involved with insightful and innovative businesses who choose to onshore. Companies benefit by locating their projects away from the mothership but near enough to retain corporate culture.

We are realigning our assets, which although enviable, were underutilized: access to the Chesapeake Bay, a great community, an uplifting quality of life, and a broadband gateway to the outside world. By creating the right partnerships through socialization and collaboration, our community will become the location of choice for many businesses currently located in our congested and expensive urban areas. Our community’s system will become "optimized." Education will improve, facilities will get built, competitive skills will get developed, local businesses will gain customers, our children will be able to work locally, and the town will prosper. We "re-power a community" through systems thinking.

In health care we intend to "empower patients" using the system thinking process. Incorporating gap analysis, one starts with the answer and works backwards. The gap we found: Too frequently, patients fall off the radar once they get discharged from the hospital. Many do not really understand what they need to do to get better and to stay out of the hospital. They are discharged unmonitored. Older people, fall victims in particular, especially if they live alone or have serious health problems. The gap we recognize: In our current system patients often cannot care for themselves but are expected to do so. How can you have continuity of care when the patient gets lost at the end of the process?

The gap we recognize: In our current system patients often cannot care for themselves but are expected to do so. How can you have continuity of care when the patient gets lost at the end of the process?

An example of systems thinking to deal with this huge gap is exemplified in the joint venture between Johns Hopkins Medicine and my company, TrustNetMD. Focused on patient enablement, we have built a system that gives care teams access to information in real time using handheld devices. Care givers can perform assessments of patient living conditions and access relevant evidence-based tasks and protocols onsite with their tablets. They can find resources for the patient; community resources like medical and mental health services, religious institutions, transportation, support groups, senior services, and clinics. Fill this gap and these patients will need less intervention, unreimbursed readmissions will drop, and long term costs go down.

So, for a proactive response to this gap, I suggest we add new components to our improving system so that we can:

• Use the internet to create a circle of care that can include family members and the community.

• Home visits to gain an understanding of patients on a personal level.

• Assess their environment. What is each patient’s situation and what resources they will need? What needs to be fixed? What is their support structure?

• Engage our entire health system. Doctors cannot be everywhere, but fortunately there are 150,000 community health workers in this country that see patients every day. We need to align this sector of our health care system in the continuity of care process.

• Embrace social media to keep people talking. Encourage caregivers to ask questions among themselves and of experts.

• Focus on patient training through knowledge sharing and education.

• Use metrics to guide future improvements.

• Use evidence-based protocols and resources to improve results.

• In essence, use all avenues to customize each situation.

We must make better use of current technologies, the cornerstone that enables systems thinking and care alignment. Our local community health workers facilitate an interaction between the patient and more formal methods of care. Accomplish this, and our patients will understand the importance of their role, and responsibility, within the health care system. The gap will be bridged.

Hospital care and population management, even though they are highly dependent, are not yet truly aligned. The challenge for health care, as an industry, is that there is a huge gap that has yet to be filled. When systems are aligned you get Amazon.com, mobile banking, Priceline, et al. In a systems thinking scenario, the health care establishment (medical staff, social workers, mental health professionals) align with support organizations (e.g., CHWs, meals on wheels) as well as IPAs, ACOs, and EBM staff, to orchestrate holistic care for all patients. An optimized system will reduce long term care cost escalation manifested in readmissions and irreversible chronic conditions. Clearly health disparities are reduced when everyone, including the patient, has access to the best, relevant, evidence-based information flowing in both directions—from research institutions down and grassroots feedback up. Enhancing communication and understanding among on-the-ground caregivers is a fundamental component of addressing improved health.

So, if you could do anything you wanted, knowing you would not fail, what would you do? If you have an answer, then there is a gap. Go fill it.

Along with a career in innovative technology, John was a Trustee in the Johns Hopkins Health System for 15 years and earned a master’s degree in Computer Science from the Johns Hopkins Applied Physics Lab. This combination of experience and education allows a broad perspective on healthcare, software and how the transfer of software platforms between industries have had a transformational impact. He believes the healthcare industry can, and should, be next.